Suspicion Of Pulmonary Embolism Research Articles

Improvement of Screening for Pulmonary Embolism with a Standardized Questionnaire

The anamnesis is believed to be poor in identifying patients with pulmonary embolism (PE), but the method of data collection may be critical for inference on this issue. We compared the prevalences of history findings recorded after a free verbal interview (VI) by the referring physicians with those recorded after completion of a standardized questionnaire (SQ) by the admitting physicians in a group of 177 consecutive patients referred to our Emergency Unit with the suspicion of PE (subsequently confirmed in 97). VI data were incomplete in 18 patients. In the remaining 159 patients, prevalences of symptoms and predisposing factors were higher after SQ than after VI. Accordingly, 8 items (obesity, prolonged immobilization, surgery, varicose leg veins, deep venous thrombosis, pleuritic chest pain, and sudden-onset dyspnea) were significantly more prevalent in patients with confirmed PE after SQ, compared to only 2 items (prolonged immobilization and pleuritic chest pain) after VI. When we tested for the agreement between the two methods of data collection, kappa values ranged from high values (for surgery and hemoptysis) to very low values (for prolonged immobilization and recurrent phlebitis). These results show that the use of an SQ could improve the accuracy of collecting clinical data in patients with suspected PE, as they are also consistent in separating patients with PE from those with unconfirmed suspicion of PE. Moreover, it allows the clinician to be alert towards findings which could be missed when not carefully searched for and which may be useful to raise or strengthen the suspicion of this disease.

Pulmonary Arteriography: The Gold Standard-Reply

Dr Sautter questions the proposed application of our decision rule that could limit the use of pulmonary arteriography in some patients with suspected pulmonary embolism (PE).¹He suggests that pulmonary arteriography should be encouraged in this population because it is a "simple procedure" that establishes a "clear... diagnosis." Certainly we agree that in patients with suspected PE a simple procedure to make the diagnosis should be used appropriately. But does Dr Sautter propose that pulmonary arteriography be performed in every patient in whom a PE is a possibility? Is it not possible that within the patient population in whom there is a clinical suspicion of PE, there exists a subset of patients in whom a PE is either so likely or so unlikely that an arteriogram would not be necessary to make the diagnosis? In our study populations, we found that not only did there exist such a stratification

Factors associated with pulmonary infarction. A discriminant analysis study.

To determine the relative importance of multiple interrelated factors that have been considered to contribute to pulmonary infarction, the authors performed a discriminant analysis on consecutively autopsied patients with pulmonary embolism. From the clinic records of 45 individuals, the authors tabulated the underlying illness, history of valvular or ischemic heart disease, right and left ventricular failure, sepsis, shock, malignancy, premortem functional status, and the clinician's suspicion of pulmonary embolism. At postmortem examination, the authors measured and recorded the extent of emphysema, pneumonia, neoplasia, pulmonary vascular atherosclerosis; thickness and dilatation of both cardiac ventricles; the presence of valvular heart disease; the number, diameter, and amount of occlusion of the pulmonary arteries that contained thromboemboli; the extension of the clot, the size of the infarct; the Reid-Index; and the thickness of pulmonary and bronchial arterial wall. The major determinants of infarction were as follows: poor premortem functional status, the number of lobes having emboli, left ventricular failure, and the presence of lung cancer. The authors then tested the equation generated from these patients on 21 additional patients. The discriminant function correctly classified 81% of first group and predicted the occurrence of infarction in new patients with 70% accuracy. The size of the infarct was most correlated with the use of vasodilators and the embolic burden.

Diagnostic Considerations in Chest Wall Tenderness-Reply

We would like to thank Dr Fred for his reply to our article. 1 It enabled us to become familiar with some of the earlier literature that we had not read previously. Dr Fred criticizes our article in two areas. First, we carefully reviewed the references he has cited. Despite a suspicion of pulmonary embolism in a number of patients, none of these studies 2-4 provide a well-documented case in which pulmonary embolism is associated with chest wall tenderness. McMillian 2 mentioned one case in which autopsy was performed, but he gives no details of the patient's course or autopsy examination. Although documentation of pulmonary embolism is inadequate in these studies, the suggestion of an association between chest wall tenderness and pulmonary embolism seems to add credence to our article. Additionally he cites two review articles 5,6 written in 1964 that were based on the forementioned studies of McMillan, 2

Digital subtraction angiography of the lung

DSA of the lung entails reduced examination risk and is a simpler procedure than conventional angiography. Out of a total of 55 lung DSA's, 53 (96%) supplied reliable diagnostic information. Suspicion of pulmonary embolism was the most frequent indication. DSA was also successfully employed in therapy control. Since other diseases of the pulmonary vessels can also be diagnosed via DSA, it can largely replace conventional pulmonary angiography. Disadvantages of DSA which must be taken into consideration are the reduced local resolution and limitations imposed by artifacts caused by patients movements.

Screening for Postoperative Pulmonary Embolism on the Basis of Clinical Symptomatology, Routine Electrocardiography and Plain Chest Radiography

The incidence of pulmonary embolism (PE) and the usefulness of various screening methods for its detection were studied in 108 patients undergoing elective hip surgery. Twenty patients had PE as shown by perfusion-ventilation lung scintigraphy. Six of them had symptoms of embolism. Clinical symptoms of PE, highly suggestive electrocardiographic (ECG) signs and signs in chest radiographs showed high specificity but low sensitivity with regard to PE. If the non-specific ECG signs and the symptoms and signs of deep vein thrombosis in the calves had also been taken into account, it would have been possible to identify 95% of the patients with PE. The use of all these screening tests revealed a suspicion of PE in two thirds of the patients. The simplest way to screen for postoperative PE seems to be to use a combination of the symptoms and signs of both PE and deep vein thrombosis, and to identify any tachycardia. This method gave a sensitivity of 85%.

Pulmonary embolism in children

The diagnosis of pulmonary embolism (PE) is seldom considered in the pediatric patient; however, pulmonary embolic phenomenon occur with a greater frequency than is generally recognized. Reports of all autopsies performed at the University of Michigan during the 25-yr period 1955 through 1979 were reviewed. All cases of pulmonary thromboembolism in infants and children ranging in age from 0 to 19 yr were studied; patients with emboli from fat or tumors and patients with primary pulmonary artery thrombosis were excluded. The records of 116 children with PE were evaluated. The sex distribution was equal and the average age was 8.0 yr. Age itself was not an independent risk factor for the development of PE. The primary disease processes of shunted hydrocephalus (15.2%), accidental trauma (8.4%), heart disease (4.5%), infection (4.4%), neoplasia (4.0%), and general medical illness (1.8%) were identified as significant risk factors for the development of pulmonary emboli. In the group with neoplasia, children with solid tumors (6.7%) were at an increased risk over the lymphomaleukemia group (2.6%) for the development of emboli. Children who had operation exclusive of the risk factors noted above (7.2%) were at an increased risk when compared to the nonoperative medical group (1.7%). Other risk factors including immobility, central venous catheterization, pre-existing hematologic disorders, and secondary infection were frequently seen. These factors, however, were not able to be studied epidemiologically. Venous thromboses were found in 40% of those children who had pulmonary emboli at the time of autopsy. Iliofemoral venous thrombosis was infrequently seen. The PE was deemed to be clinically important in 30% of the total series. In patients with clinically significant PE, only 50% had documented signs and symptoms of embolization and an antemortem diagnosis was considered in only one-third of these symptomatic patients. The total incidence of PE did not change over the 25-yr period, nor were there any significant trends in the associated risk factors. This study supports the concept that PE occurs in children with a greater frequency than is commonly recognized. Signs and symptoms of clinically significant pulmonary emboli occur in only 50% of the patients and even when the event presents clinically, it is an underdiagnosed entity. A heightened index of suspicion for PE in children is warranted. The diagnosis of pulmonary embolism (PE) is seldom considered in the pediatric patient; however, pulmonary embolic phenomenon occur with a greater frequency than is generally recognized. Reports of all autopsies performed at the University of Michigan during the 25-yr period 1955 through 1979 were reviewed. All cases of pulmonary thromboembolism in infants and children ranging in age from 0 to 19 yr were studied; patients with emboli from fat or tumors and patients with primary pulmonary artery thrombosis were excluded. The records of 116 children with PE were evaluated. The sex distribution was equal and the average age was 8.0 yr. Age itself was not an independent risk factor for the development of PE. The primary disease processes of shunted hydrocephalus (15.2%), accidental trauma (8.4%), heart disease (4.5%), infection (4.4%), neoplasia (4.0%), and general medical illness (1.8%) were identified as significant risk factors for the development of pulmonary emboli. In the group with neoplasia, children with solid tumors (6.7%) were at an increased risk over the lymphomaleukemia group (2.6%) for the development of emboli. Children who had operation exclusive of the risk factors noted above (7.2%) were at an increased risk when compared to the nonoperative medical group (1.7%). Other risk factors including immobility, central venous catheterization, pre-existing hematologic disorders, and secondary infection were frequently seen. These factors, however, were not able to be studied epidemiologically. Venous thromboses were found in 40% of those children who had pulmonary emboli at the time of autopsy. Iliofemoral venous thrombosis was infrequently seen. The PE was deemed to be clinically important in 30% of the total series. In patients with clinically significant PE, only 50% had documented signs and symptoms of embolization and an antemortem diagnosis was considered in only one-third of these symptomatic patients. The total incidence of PE did not change over the 25-yr period, nor were there any significant trends in the associated risk factors. This study supports the concept that PE occurs in children with a greater frequency than is commonly recognized. Signs and symptoms of clinically significant pulmonary emboli occur in only 50% of the patients and even when the event presents clinically, it is an underdiagnosed entity. A heightened index of suspicion for PE in children is warranted.

The diagnosis of pulmonary embolism with gammacamera. A comparison with clinical, radiological and electrocardiographic findings.

Abstract A retrospective analysis has been performed on patients investigated with pulmonary scintigraphy on suspicion of pulmonary embolism. Seventy‐four patients have been investigated during a 2‐year period and a comparison has been made between clinical diagnosis, scintigraphy, chest X‐ray and ECG. The method of scintigraphy is described and evaluated. Scintigraphy is of considerable value in the diagnosis of pulmonary embolism as it is a simple procedure for the patient, well correlated to clinical findings, as well as giving good quantitative data. It also allows for an evaluation of therapeutic results. Chest X‐rays provide poor information, and characteristic ECG changes are only seen in the most advanced cases.